Community Transition Liaison Program

The Commonwealth of Massachusetts has committed to deinstitutionalizing 2,400 nursing facility residents over the next eight years and return people to the community with needed supports. $1 billion is being invested in housing, counseling, and other services to help people leave nursing facilities. Despite the billion-dollar investment, there will likely be money saved as people move out of nursing homes into less expensive forms community-based care [source: State promises $1B to move 2,400 out of nursing homes after settling class action lawsuit – McKnight’s Long-Term Care News (].

Launched as an initiative from the Massachusetts Executive Office of Elder Affairs in 2023, the Community Transition Liaison Program (CTLP) offers professional support including individually tailored discharge plans, connections to state program and local supports, and dedicated advocacy to nursing facility residents who want to return to the community. CTLP services are free for all nursing facility residents aged 22 and over, regardless of insurance status.

Transitioning to the community can mean returning to a family home, moving into accessible housing, or another residential facility that provides needed support while maintaining resident independence. Everyone’s situation is unique and is approached by CTLP staff in individualized ways. Regardless of where a consumer is discharging to, our CTLP team works with residents, families, and nursing facility staff to ensure the complex process is navigated effectively.

SeniorCare serves nine communities on Boston’s North Shore, including Beverly, Essex, Gloucester, Hamilton, Ipswich, Manchester-by-the-Sea, Rockport, Topsfield, and Wenham, including six nursing facilities in our area. Whether you or a loved one are seeking to transition out of one of our covered facilities or are transitioning to our community from another nursing facility in the state, our CTLP team can:

  • Assist with determining eligibility to supportive programs, services, or housing as needed;
  • Assist with obtaining documentation for programs or services, including helping to complete applications and necessary paperwork;
  • Assist with the communication flow between the nursing home resident and nursing facility staff throughout the discharge process; and
  • Help the nursing home resident and/or family members understand resources that may be available to them and assist them in accessing those resources.

To learn more about how to enroll in SeniorCare’s Community Transition Liaison Program (CTLP), ask your facility’s social worker or contact our Community Transition Liaison at 978-281-1750.